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KEY WORDS W. James Gardner hydromyelia trigeminal neuralgia skull tongs neurological history JAMES Gardner (18981987) is best remembered for his skull tongs and his theories on congenital hindbrain abnormalities and hydromyelia. Few of todays practitioners, however, know about the breadth and depth of the accomplishments of this great teacher and pioneer neurosurgeon. Gardners career straddled the transition of neurosurgery from an art practiced by few individuals to a science that has evolved into the current complex array of subspecialities. Through his diverse activities in the academic neurosurgical arenas of patient care, education, and clinically relevant research, Gardner helped to strengthen the fledgling discipline. During his three decades at the Cleveland Clinic, he served actively in many important capacities and strongly believed in and enjoyed the concept of group practice. In addition, the tradition of clinical research and academic excellence established by Gardner laid the foundation for the accomplishments of the neurosurgery department at his institution and continues to be an important part of its mission.
Biographical Sketch W. James Gardner was born in McKeesport, Pennsylvania on June 12, 1898, and attended McKeesport High
Abbreviations used in this paper: CSF = cerebrospinal fluid; LP = lumbar puncture; TN = trigeminal neuralgia.
School. He spent his boyhood summers hunting and fishing in the Allegheny forest and maintained this love of outdoor activity throughout his life. Both of Gardners parents, his two sisters, and their housekeeper died of tuberculosis before he finished high school. He received a B.A. degree from Washington and Jefferson College in 1920 and on graduating from medical school in 1924 was appointed to a 2-year rotating internship at the University of Pennsylvania. Gardners father, Gardner, and his son (William James Gardner III) all graduated from the University of Pennsylvania in (1894, 1924, and 1954, respectively), thereby keeping intact the family tradition of graduating a James Gardner every 30 years from the University of Pennsylvania. He married a clinical psychologist, Ann Ray Kieffer, in 1928. He participated in sports with the same zeal and energy that he gave to his scientific pursuits. He took up tennis and ice skating, whereas his skiing career was cut short when he broke his tibia in an accident. He was an excellent dancer, even inventing shoes for dancing on carpet, was a member of a barbershop quartet of colleagues from the Clinic, and thoroughly enjoyed giving and attending a good party. Gardner and Frazier: The University of Pennsylvania (19261929) Two key events were to occur in Gardners life that led to
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the now busy service. Clinic records show that George Crile Sr. (one of the four Cleveland Clinic founders and a cofounder of the American College of Surgeons) had written to Frazier, expressing interest in Francis Chubby Grant. Frazier, though, who had approximately 5 years left until his retirement, wanted Grant to take over the unit at the University of Pennsylvania. Frazier instead recommended Gardner for the position. By coincidence, Gardner was scheduled to present a paper on the therapeutic effects of encephalography at a meeting of the Pennsylvania State Medical Society in Erie in September 1929. Dr. Lower, a urologist and another of the Clinics founders, was in attendance specifically to invite Gardner for a visit to the Clinic. Gardner accepted and was entertained that evening by the Criles and Lowers. The following morning he was escorted to the Clinic by Dr. Lower, purportedly to meet the staff. Instead Gardner was taken to the bed of a patient who 2 weeks previously had been surgically treated by a general surgeon for an unlocalized brain tumor. A right subtemporal decompression had been performed but no tumor had been disclosed. On clinical examination, Gardner found that the patient exhibited papilledema with a Broca aphasia and made a diagnosis of a left temporal tumor. Lower then suggested that Gardner remove the tumor; however, Gardner declined because he had commitments in Philadelphia the next day. Lower then led Gardner to the surgical pavilion where an operating room was prepared for a craniotomy. Unable to resist the opportunity to demonstrate his surgical skills, Gardner performed a large left-sided osteoplastic flap, removed a large globular meningioma, and finished the surgery in 2 hours and 20 minutes. With this display of his clinical acumen and surgical skill, the job was his with a salary of $6000 per year.16 Luck was on Gardners side; the stock market crashed 30 days later and the Great Depression began in the US. So began his career as Chief of Neurological Surgery at the Cleveland Clinic, an association that was to last for 33 years. After he stepped down as chief in 1962, he was a senior consultant with the department until his first retirement in 1964. Postretirement Years (19641974) After mandatory retirement from the Cleveland Clinic in 1964 at the age of 65 years, Gardner opened a private practice in the Greater Cleveland area, was the head of neurosurgery at the Fairview General Hospital (19641967), and was on the staff at the Huron Road Hospital from 1964 to 1974. With the establishment of an emeritus program at the Cleveland Clinic, he rejoined the Department of Neurosurgery staff after his second retirement in 1974. Gardners Contributions to Neurological Surgery Gardners busy and diverse practice at the Clinic placed him in a unique position to make contributions in many aspects of neurosurgery. A brief review of some of his important contributions follows. Neurotrauma Chronic Subdural Hematomas In 1946, while he was operating with Albert LaLonde (a
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The second happenstance to alter Gardners life was the Cleveland Clinic disaster. On May 15, 1929, an explosion of smoldering x-ray films occurred in the basement of the outpatient department of the Clinic. The poisonous gas that was released took the lives of 123 people, including the clinics first neurosurgeon, Charles E. Locke, who had trained with Harvey Cushing. This accident led to the development of a new composition for x-ray films and to new regulatory processes regarding their storage. The clinic, as the result of this catastrophe, found itself badly in need of a neurosurgeon to assume the leadership of
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encounter. He therefore made an impassioned plea . . . that less qualified surgeons in spine must be discouraged from expanding into this essentially neurosurgical field which is fraught with pitfalls for the inexperienced. Hydrodynamic Theory for Congenital Hindbrain Anomalies Gardners hydrodynamic theory on the pathophysiology of syringomyelia and other dysraphic states was based on his clinical experiences.16 In brief, Gardner believed that each systolic pulse generated a pressure gradient throughout the CSF (Bering effect) that tended to force the CSF out of the ventricles. He suggested that this hydrodynamic effect was responsible for the formation of the subarachnoid pathways when the rhombic membrane ruptured, but that it also played a role in shaping the developing brain. If failure or inadequate rupture of the rhombic membrane occurred (fourth ventricular outlet obstruction), the pulsatile CSF would then flow through the patent obex and enter the central canal with the resultant water-hammer pulse effect causing dilation of the central canal, leading to syringomyelia, whereas an open neural tube was due to overdistension and rupture rather than failure to close.7,8,12,21,27,33,35,36, 41,43 Therefore, depending on the delicate balance between lateral ventricle and fourth ventricular choroid plexus pulsatility, he believed that the DandyWalker and Chiari malformations were part of the same spectrum of disease, and that both were caused by embryonal hydrocephalus. Gardner was a steadfast believer in and defender of the hydromyelic theory of Morgagni, which was proposed in 1769. In his 1960 paper on myelomeningocele Gardner22 starts off with a quote from Roger Bacon (ca. 12141294) about the four stumbling blocks of truth, and goes on to criticize Von Recklinghausen, who in 1886 discredited Morgagnis hydromyelic theory. Furthermore, Gardner believed that solely on the basis of appearance, Von Recklinghausen assumed that myeloschisis represented a failure of neural tube closure rather than rupture, as Gardner believed. He goes on to state that Therefore to this day, because of custom and influence of the great Von Recklinghausens authority, the araphic theory has gone unchallenged even though embryological, pathological, clinical, and experimental evidence favors Morgagnis less fragile hypothesis. In 1973, using a combination of his clinical experience as well as expertise in physics, physiology, embryology, anatomy, and ultrastructure, Gardner published his monograph called The Dysraphic States: From Syringomyelia to Anencephaly. Recently, Gardners hydrodynamic theory has been partially corroborated with magnetic resonance imaging findings.66 Functional Neurosurgery Hemifacial Spasm and TN Gardners lifelong interest in TN began during his residency in 1926. As early as 1915, Frazier began to practice subtotal sectioning of the sensory root and in 1918 he proposed sparing the motor root. This latter technique was put to the test when a distinguished lady from Lima, Peru, who had been surgically treated by Frazier in 1917, returned with pain on the contralateral side. During the previous sur967
After Lindbloms initial description in 1948, the first lumbar discography in the US was performed at the Cleveland Clinic by Wise and Weiford in 1951, with Gardner, et al.,42 following shortly thereafter in March 1952 with the second paper. The next 89 cases in which this modality was used were reported by Wise, et al.,72 in June 1952; an additional 165 lumbar discographies were later reported in 1957.71 In 1962, Collis and Gardnes2 described their experience examining 1014 cases, the largest series reported at that time. Four hundred ninety-three of 1014 patients who underwent lumbar discography subsequently underwent surgery in which fewer interspaces were explored surgically, resulting in less trauma to nerve roots, while the incidence of multiple herniations was 1.5% (410 surgically verified herniated discs in 404 patients). In the discussions that followed its publication, the paper received mixed reviews, with Ralph Cloward strongly endorsing the results. In 1951, both Gardner and Cloward independently exhibited their technique of lumbar discography at the American Medical Association convention in Atlantic City.
Epidural Steroid Delivery/Pantopaque Arachnoiditis
Based on his previous work with Seghal on corticosteroid agents administered intradurally for relief of sciatica,67 Gardner, Sehgal, and Dohn15 published in a nonpeer reviewed journal their experience with subarachnoid injections of methylprednisone acetate for patients suffering from Pantopaque arachnoiditis. In 60 of 100 patients they managed to reduce the radicular pain with no adverse effects for a period of up to 2 years.
Spinal Specialization
By the 1960s, after a neurosurgical career spanning more than 3 decades and having witnessed the increasing specialization of surgery for spinal degenerative diseases, Gardner sent out a questionnaire to all neurosurgical chiefs to evaluate current trends in disc surgery in their units. In an invited editorial published in Surgery Gynecology and Obstetrics in 1965, Gardner12 wrote, The surgeon who operates within the spinal canal should be prepared by training and experience to handle any type of surgical lesion that he may
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sympathetic blocks for cerebral embolus, thrombosis, and causalgia of the upper limbs, and for trauma to the brain. In 1946, Karnosh (a neuropsychiatrist at the Cleveland Clinic), Gardner, and Stowell62 reported the effects of temporary cerebral sympathectomy accomplished by bilateral stellate ganglion blocks on organic brain diseases and psychoses.60,61 This discovery occurred incidentally in January 1946 when a 38-year-old woman received bilateral stellate blocks for cerebral embolus accompanied by hemiplegia and DejerineRoussy syndrome. This led to the implementation of this procedure in a series of patients with cerebral vascular disease, brain atrophy, and Parkinson disease. Most patients were enthusiastic about the improvement that they claimed the procedure produced, although motion picture analysis revealed no improvement in motor function and it was believed that this apparently impressive improvement in mood was caused by the sympatholytic effects. Karnosh and Gardner decided to try bilateral stellate ganglion procaine blocks in a small group of patients suffering from depression and anxiety and in patients with known schizophrenia. In three patients with depression, the temporary sympathetic block resulted in an improvement of affect, a relative euphoria, transient relief from suicidal ideation, and psychomotor retardation. No effect was observed in psychotic patients.59 Gardner: As Inventor Gardner believed that his research had to have a direct clinical application, otherwise he would pay the issue scant attention. Despite his immense clinical workload, he still had the energy to explain clinical phenomena and help sick patients, and never went without some project to occupy his time. Each problem was followed through with dogged determination even though the initial results were often enough to discourage the most enthusiastic researcher. His inventiveness, combined with hard work and determiation, was among his greatest attributes. We briefly review some of his inventions.
The Gardner Neurosurgical Chair (1938)
During his residency, Gardner learned that Frazier had recognized the tremendous advantage of placing a patient in the sitting position while performing surgery for TN.16,19 Frazier commented that this position prevented a puddle of blood from covering the nerve filaments, placed the operative field comfortably at the level of the surgeons eyes, and that smaller amounts of anesthetic agents could be used. In addition, de Martel started using the sitting position in 1911 and found that it decreased hemorrhage and aided respiration. De Martel favored operating with the patient in the sitting position after induction of local anesthesia so that early recognition of syncope could be corrected by lowering the patients head. Gardner mentions one occasion when Frazier, on returning from a visit to de Martels clinic in Paris, recounted what he saw when the famous French neurosurgeon performed surgery while the patient received local anesthesia. De Martel had apparently performed a suboccipital craniectomy for a cerebellar tumor in an 11-year-old girl whom he made straddle a wooden chair, cross her arms on its back, and rest her head on her forearms. Frazier described this as a horrible exhibition.16
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Although Fulcher was the first to report the use of tantalum in repairing a cranial defect, it was Gardner who popularized this material (pure metal: 73rd element in the Periodic Table). Using a thinner sheet (to reduce the degree of radiopacity) cut by conventional scissors and molded, Gardner advocated its use in primary repair of cranial defects,29,70 even in the presence of intracranial infection.32
Constant Traction Dressing (1945)
Gardners war experience fueled his interest in cranial wounds.14,25,29 Together with Seitz, a research engineer at the Cleveland Clinic, he developed the constant traction dressing which was more comfortable than the usual gauze dressing.45 More importantly, however, the skin edges underwent progressive approximation resulting in a narrower scar, in some cases averting the need for secondary suturing and/or skin grafting.13 The dressing consisted of two metal members (0.004 in thick) connected by a sheet of latex. The metal spurs were short so that they only penetrated the stratum corneum and did not cause pain. As approximation of the wound occurred, shorter dressings were applied.48
Induced Hypotension for Hemostasis (1946)
FIG. 1. Photograph showing the Gardner neurosurgical chair. The chair could be raised or lowered by a foot pump and also rotated around a vertical axis. Using a crank, it was tilted backward like a rocking chair so that the patients feet could be higher than the head. It still provides more favorable positioning for cranial surgery with the patient sitting than most modern surgical tables. A slot in the back allowed the surgeon to perform an LP during surgery, if required. By adding a table top to the backward-tilted chair and a three-point head fixation device, the supine patient could be readied for craniotomies. The chair was also accompanied by a lifter that could lower the patient into an adjacent bed.
Gardner was the first to apply the method of controlled hypotension during surgery as an aid to hemostasis.10,39 He believed that intravenous transfusions given to a patient in severe shock must pump the intravenous injected blood through the pulmonary circulation and then out into the aorta, before the heart itself can benefit. Believing that the primary function of the heart was to maintain a normal level of pressure in the elastic aorta and that patients in severe shock who were given intravenous fluids would experience an additional strain on an already ischemic heart, he thought that intraarterial infusion of fluids would restore the cerebral and coronary blood flow more rapidly before the burden of an increase in venous pressure and blood volume are thrown onto the weakened heart (Page procedure). This, according to Gardner, appeared to be a more physiological than intravenous infusion of the blood in severe hemorrhagic shock. He reported the beneficial effects of controlled hypotension in 161 patients during a 6-year period (1946 1953). Forty-six of 161 patients with difficult intracranial meningiomas who were treated using the Page procedure were compared with another group of 44 patients in whom intracranial meningiomas were surgically treated during
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the same period. A mortality rate of 8.7% (Page procedure) compared with 13.6% (without the technique) was recorded. For cerebral aneurysms, Gardner preferred to induce hypotension with one of the ganglion blocking drugs rather than the Page technique. In his paper on meningioma and hypotension, Gardner mentions that surgeons with their natural repugnance to blood loss have been slow to adopt a procedure which entails deliberate removal of blood from the circulation. Illustrative of this reluctance, Gardner notes that one advocate of the total spinal method had referred shudderingly to the Page procedure as the oligemic shock method.42
Alternating Pressure Pad (1948)
Gardner developed the alternating pressure pad (Fig. 2) and used it first at the Clinic in July 1947. He analyzed 100 consecutive patients in whom the mattress was used and found the value of the pressure pad to be so obvious that all patients who required the pad were given this form of care, so that he was unable to perform a subsequent randomized study. Gardner calculated that he saved 1 hour of a nurses time per patient per day with the pressure pad.23,43
The Clinical G Suit (1956)
Following his service in World War II, Gardner realized the potential of the antigravity suit that prevented blackouts in fighter pilots. He modified the G suit to consist of two sheets of vinyl plastic sealed at the edges to form a large inflatable bladder that was placed beneath the patient. The edges were folded over so that the patient was enclosed from the rib cage to the ankles, and the entire contraption
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FIG. 2. Photograph showing alternating pressure pad. The alternating pressure pad mattress is constructed of a flexible waterproof plastic material. The apparatus consists of a pneumatic mattress with air cells 3 cm in diameter that run transversely the width of the mattress, with alternate cells connected to a manifold that constitutes the edge of each side of the mattress. Alternating inflation and deflation of the transverse cells occurs at intervals of 2 to 3 minutes so that the patients body is alternately resting on the odd-numbered cells and then on the even-numbered cells. The inflation and deflation of the two air systems is driven by a small air pump.
FIG. 3. Photograph showing the clinical G suit, which consisted of two sheets of vinyl plastic sealed at the edges to form a large inflatable bladder, so that the patient was enclosed from the rib cage to the ankles; the entire contraption was drawn snug by lacing. The system included a manometer and the suit was inflated by a gas tank.
was drawn snug by lacing. The system had a manometer and was inflated by a gas tank (Fig. 3). If a patient experienced hypotension while in the sitting position or if Gardner anticipated hypotension in any position, the clinical G suit could be inflated in a matter of seconds.17,50 The clinical G suit helped save the life of a staff members wife after she developed postpartum hemorrhaging which, after 11 hours of futile surgical efforts to control intraabdominal bleeding, had resulted in 56 blood transfusions administered over a period of 18 hours. She was placed in the G suit at a pressure of 20 mm Hg and this raised her blood pressure, stopped the bleeding, and saved her life.52 In their 1956 paper, Gardner and Dohn wrote that while doing a literature search, they discovered that one of the earliest descriptions of the antigravity suit had been made by George Crile Sr.3 in 1903. He abandoned this work, however, because of technical difficulties with his suit (constructed from India rubber), while at the same time improving methods that had been developed for blood transfusion. The principle of applying the G suit to combat hypotension has been documented in many publications.4,6,17,50
Hypothermia With Temporary Occlusion of Major Brain Arteries by Pneumatic Cuffs (1956)
expanded the cellophane tube, thus occluding the artery. In applying the device, the cellophane tubing was passed twice around the common carotid artery with the distal end tied to the proximal end, where it was fastened to the catheter. To occlude the vertebral artery, it was only necessary to expose a cervical vertebral foramen and draw the cellophane cuff partly through it. The four catheters were then connected by a series of T-tubes to an ordinary blood pressure apparatus so that all four arterial cuffs could be simultaneously activated.46 To induce hypothermia, Gardner, Wasmuth (an anesthesiologist), and Hale35 converted an operating table into a refrigerating trough by enclosing the patient in a watertight plastic sheet draped over a rectangular frame and then submerging only the body in ice water.
GardnerWells Cervical Traction Tongs (1959)
Gardner developed pneumatic cuffs that were used to occlude the four major arterial vessels to the brain simultaneously during aneurysmal rupture so that the surgeon could ligate or clip the aneurysm while the patient was in a state of hypothermia.46 One end of moistened cellophane tubing (1 cm in flat width and 8 cm in length) was tied to the amputated end of a No. 8 French gauge soft rubber catheter into which a 16-gauge syringe had been previously inserted on the opposite end. The other end of the cellophane tubing was ligated and both proximal and distal ends were tied, thus forming a loop with the No. 8 French catheter protruding from one end of the tubing with the syringe on its opposite end. Air from the syringe introduced into the catheter
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In 1959 Gardner developed his cervical skull traction tongs and later, with Wells, improved the design for emergency bedside application under antiseptic rather than aseptic conditions. His design maximized the mechanical efficiency of the tong for cervical traction by repositioning the upward-directed tapering pins to engage in the outer table of the temporal bones at points between the ears and the skulls equator (Fig. 4). The principal advantage over the Crutchfield tongs was that no shaving was necessary, and after application of a local anesthetic agent, advancing the tapered points through the scalp caused the stretched skin to fit snugly about the pins, thereby sealing their point of entry, which prevented bleeding. One of the points was rendered retractable by an enclosed spring that was calibrated to indicate the pressure. On encountering bone, the stiff spring yielded until the outer end of the spring-loaded point barely protruded beyond the flat surface of the knurled end. Gardner later simplified the construction and developed safeguards against perforations of the inner table.1,24 The Gardner tongs are now widely used in many institutions.
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FIG. 4. Photograph showing the GardnerWells cervical traction tongs. The main structural element is a rigid C-shaped metal bar that roughly conforms to the coronal suture of the skull. Sharp tapered pins positioned at an upward angle at the ends of the C-shaped metal structure are screwed into the skull.
Gardner developed a waterbed for children who were prone to pressure sores due to hydrocephalus. The infant was floated on a bag of water, which was made redundant and relaxed by placing it in a box or crib. An alarm system was incorporated to detect leakage and the water temperature could be thermostatically controlled. Gardner also developed a hammock that prevented an infant with scaphocephaly from resting on the flat side of its head, thereby preventing an increase in the deformity.40
The G Splint (1962)
The G splint (Immobil-Air), developed in 1962, was a spinoff from the clinical G suit. This pneumatic splint, inflated by mouth in a matter of seconds, was designed as a first-aid device to be used in an emergency to stabilize the patient from hemorrhaging in the extremity and to immobilize the broken limb. This pneumatic splint was a doublewalled sleeve of transparent plastic film in which air was forced between the two layers, resulting in compression of the limb by the inner layer, whereas the outer layer tended to elongate, exerting a splinting effect and traction.18 After delivering a lecture on syringomyelia to the neurosurgery staff at McGill University in Canada, Gardner noticed Wilder Penfield walking with a slight limp in the cafeteria. While picking up his food tray, Penfield experienced a sudden pain in his knee. Raising his trouser leg, a rapid swelling in the knee due to spontaneous hemorrhage was diagnosed; this occurred in an old knee injury sustained when a torpedo in World War I struck Penfields destroyer. An orthopedist present in the cafeteria ordered immediate bed rest and a compression bandage. Gardner, however, had a sample of the G splint with him, and he quickly applied it directly over the trouser on Penfields leg, thus stopping the bleeding. Penfield subsequently wrote to Gardner requesting another splint and in his letter of thanks he mentioned that he never subsequently left home without it.16
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His pioneering contributions to neurosurgery occurred in several other areas such as cerebral hemispherectomy26 in the treatment of glioma, and treatment of carotidcavernous fistula by muscle embolization.58 Among Gardners other lesser known inventions was his adaptation of the Souttar craniotome (1929) soon after arriving at the Cleveland Clinic (this was used until power tools for opening the skull were introduced in the 1960s);16 the development of a neurosurgical suction irrigator;64 modification of the respirator with D. E. Hale (1948);57 recording time on roentgenograms (1954);51 and a ventriculomastoid shunt in which a Holter valve was used for the treatment of hydrocephalus (1962).5 Conclusions W. James Gardner was a pioneer neurosurgeon, scientist, inventor, and educator (Fig. 5). Many of his contributions to the field are now taken for granted. His theories on the pathogenesis of several neurological disorders have stood the test of time or have served as the foundation on which contemporary theories rest. In total, Gardner trained 28 neurosurgeons and 14 others served their fellowships with him; this was in addition to the many general surgical residents who passed through his service. His genius has not gone unrecognized by neurosurgical organizations and the Cleveland Clinic. During his neurosurgical career, Gardner was active in many national and regional organizations. He was President of the Society of Neurological Surgeons, Vice President of the Cushing Society, on the Board of Governors of the American College of
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63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73.
Manuscript received September 24, 2003. Accepted in final form January 12, 2004. This paper will be presented in part at the 72nd Annual Meeting of the American Association of Neurological Surgeons May 16, 2004, Orlando, Florida. Address reprint requests to: Gene H. Barnett, M.D., Brain Tumor Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195. email: barnett@neus.ccf.org.
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